Simulation Training in Neuroangiography-Validation and Effectiveness

Diagnostic and interventional neuroradiology training in the UK: a national trainee survey

AIM

Training structure in neuroradiology can be variable, nationally and internationally. Globally, there is a trend towards standardised training pathways, curricula and targeted competencies. Currently, there is limited understanding of the structure of neuroradiology training in the UK. This survey aims to: [1] identify different contemporary models of neuroradiology training in the UK, [2] compare UK trainees' commitments against national and international standards, and [3] understand whether career expectations match the predicted future demands of neuroradiologists.

MATERIALS AND METHODS

A survey was developed after consultation with BSNR and UKNG representatives. The eligibility criteria included current neuroradiology trainees in the UK with at least 3 months of experience or had recently completed neuroradiology training, but less than 18 months had elapsed since achieving a certificate of completion of training.

RESULTS

A total of 50 trainees responded to the survey; 26 (52%) diagnostic neuroradiologists (DNRs) and 24 (48%) interventional neuroradiologists (INRs) with an overall mean age of 33 years. The mean duration of training at the time of survey was 18 months. The survey details trainee demographics, experience at work, research and teaching commitments and future goals.

CONCLUSION

Most respondents are satisfied with their training and 90% want to remain in the UK after completion of training. There is room for improvement but the future of training and working in neuroradiology seems promising internationally, with ever-evolving techniques and developments.

ADVANCES IN KNOWLEDGE

Advances in knowledge: This study evaluates neuroradiology training in the UK to enhance the training of future neuroradiologists, and safeguard the future of the speciality.

Differences in beginner and expert neurointerventionalists" heart rate variability during simulated neuroangiographies

BACKGROUND

Likewise work experience, heart rate variability (HRV) has repeatedly been correlated with improved performance under real life and simulator conditions. Using HRV as a correlate of workload, it is meaningful to assess the impact of work experience. To understand the impact of work experience on HRV metrics, we examined differences in HRV among experts and beginners during simulated endovascular neuroradiological procedures.

METHODS

Six inexperienced radiologists (beginners) and five experts in neurological endovascular intervention each performed 10 diagnostic angiographies on a Vascular Interventional System Trainer (VIST) simulator (Mentice AB, SW). Beyond total time, fluoroscopy time, and amount of contrast medium used, heart rate variability and the NASA-task load index were gathered as correlates of workload. The t-Test for independent samples as well as Mann-Whitney-U tests were applied for group-wise comparison between beginners and experts. Multivariate regression was used to assess the influence of age and expert status.

RESULTS

Ten participants completed all scenarios; one participant only completed the first five scenarios. Accordingly, 105 simulations were analyzed (beginners N = 60; experts N = 45, respectively). The heart rate variability of experts and beginners significantly differed in three time domain HRV metrics (decreased RMSSD, NN50, pNN50 in experts; all p < 0.05) as well as with respect to its distribution in the frequency spectrum (LF/HF ratio; p < 0.001, increased high frequency components in experts).

CONCLUSIONS

The HRV of beginners and expert neurointerventionalists significantly differed during simulated endovascular neuroradiological procedures. Experts presented decreased HRV, this could be a cardiovascular surrogate to the effort the subjects expend on their performance. It is in line with previous studies on vagal influences on the heart and cognitive-executive performance.

Questionnaire Survey of Neurointerventional Simulation Training in the Japanese Society for Neuroendovascular Therapy

Objective

Simulation training has focused on education and practical training. However, the adoption rate of neurointerventional simulation training in Japan is unknown. Therefore, we sent a questionnaire survey form to consulting specialists from the Japanese Society for Neuroendovascular Therapy (JSNET) to clarify the actual simulation training situation and compare the differences between university hospitals and general hospitals in Japan.

Methods

The questionnaire survey was conducted in 243 neurosurgical training facilities that had JSNET consulting specialists between May 31, 2021 and July 31, 2021. The questionnaire survey forms were distributed by Google Forms.

Results

A total of 162 facilities responded to the survey (response rate: 66.7%; 35.2% from university hospitals and 64.8% from general hospitals). The adoption rate for simulation training was 53.7%, and it was significantly higher in the university hospitals than in the general hospitals (64.9% vs. 47.6%, p = 0.035). On the simulation effectiveness survey, more than 80% of respondents answered that the simulation training was a useful tool for upskill training. The open-ended question on interventional simulation training showed that there are limiting factors such as financial constraints. Additionally, respondents expressed a desire for a standard neurointerventional simulation training and education program.

Conclusion

The adoption rate for simulation training was 53.7% in the training facilities of JSNET, and it was higher in the university hospitals than in the general hospitals. Most of the respondents answered that simulation training is an effective tool to improve neurointerventional skills. They also requested the establishment of simulation training programs and simulation tools.

Feasibility of Network-Based, Online Endovascular Simulator Training in Real Time: Results from a Pilot Study

PURPOSE

 To test the feasibility of an online, simulator-based comprehensive interventional radiology (IR) training curriculum in times of COVID-19-induced travel restrictions.

MATERIALS AND METHODS

 A network of six VIST simulators (Mentice, Gothenburg, Sweden) was installed in six geographically different radiology departments. Two courses with six sessions each took place. 43 participants were recruited on a voluntary basis among local residents. The training sessions were conducted in real time with interconnected simulation devices and were led by experts in the field of IR on a rotational basis. The participants attitude toward various topics was quantified before and after training on a seven-point Likert scale (1 = "not at all", 7 = "to the highest degree"). In addition, post-course surveys were conducted.

RESULTS

 The courses led to an improvement for all items compared with baseline: interest in IR (pre: 5.5, post: 6.1), knowledge of endovascular procedures (pre: 4.1, post: 4.6), likelihood of choosing IR as a subspecialty (pre: 5.7, post: 5.9). Experience with endovascular procedures (pre: 3.7, post: 4.6) improved significantly (p = 0.016). In the post-course surveys high satisfaction rates with the pedagogical approach (mean 6), the teaching content (mean 6.4), and the duration and frequency of the course (mean 6.1) were observed.

CONCLUSION

 The implementation of a simultaneous endovascular online training curriculum in different geographic locations is feasible. The curriculum has the potential to meet the demand for training in IR in times of COVID-19-associated travel restrictions and can complement future training in the context of radiologic congresses.

KEY POINTS

  · The implementation of a simultaneous endovascular online training curriculum in different geographic locations is feasible. For interested residents, the presented online curriculum can offer a low-threshold and comprehensive entry into the world of interventional radiology at the site of their training..

Visuo-motor transformations in the intraparietal sulcus mediate the acquisition of endovascular medical skill

Performing endovascular medical interventions safely and efficiently requires a diverse set of skills that need to be practised in dedicated training sessions. Here, we used multimodal magnetic resonance (MR) imaging to determine the structural and functional plasticity and core skills associated with skill acquisition. A training group learned to perform a simulator-based endovascular procedure, while a control group performed a simplified version of the task; multimodal MR images were acquired before and after training. Using a well-controlled interaction design, we found strong multimodal evidence for the role of the intraparietal sulcus (IPS) in endovascular skill acquisition that is in line with previous work implicating the structure in visuospatial transformations including simple visuo-motor and mental rotation tasks. Our results provide a unique window into the multimodal nature of rapid structural and functional plasticity of the human brain while learning a multifaceted and complex clinical skill. Further, our results provide a detailed description of the plasticity process associated with endovascular skill acquisition and highlight specific facets of skills that could enhance current medical pedagogy and be useful to explicitly target during clinical resident training.

School of Thrombectomy-A 3-Step Approach to Perform Acute Stroke Treatment with Simulator Training and Virtual Supervision by Remote Streaming Support (RESS)

As the number of neurointerventional procedures continues to increase, so does the need for well-trained neurointerventionalists. The purpose of this work was to establish and assess a systematic 3‑step approach to perform acute stroke treatment including simulator training and virtual supervision by remote streaming support (RESS). Five trainees (four men, one women) who have completed the 3‑step approach have answered an 11-item questionnaire (5-point Likert scale) in order to evaluate training step 1 (simulator). Furthermore, all trainees and one supervisor (female) answered a standardized questionnaire following the initial 15 consecutive thrombectomies for each trainee, corresponding to a total of 75 thrombectomies. The simulator training yielded learning benefits and confidence gain to perform MT on patients. The RESS approach facilitated the translation during the first independently performed thrombectomies on patients. In summary, the presented 3‑step approach increases the level of safety, as reported by the trainees and supervisor in this study and may enable an accelerated training of neurointerventionalists.

The pioneering past and cutting-edge future of interventional neuroradiology

This review provides a thorough understanding of the developments in the field of interventional neuroradiology (INR). A concise overview of the pioneering past and current state of this field is presented first, followed by a greater emphasis on its future. Five main aspects predicted to undergo significant developments are identified and discussed. These include changes in 'education and training', 'clinical practice and logistics', 'devices and equipment', 'techniques and procedures', and 'relevant diagnostic imaging'. INR is at the crossroads of neuroradiology, neurosurgery, neurology, and the neurosciences. To progress we must value the uniqueness and vitality of this multidisciplinary aspect. While minimal access techniques offer very good anatomical accessibility to treat multiple pathologies of the central nervous system, it is also important to recognise its limitations. Medical, surgical, and radiosurgery modalities retain an important role in the management of some complex neuropathology. This review is certainly not exhaustive of all ongoing and predicted developments, but it is an important update for INR specialists and other interested professionals.

How We Do It: A Multicenter National Experience of Virtual Vascular Surgery Rotations

OBJECTIVE

To describe the development and implementation of virtual vascular surgery rotations among 6 integrated vascular surgery programs.

DESIGN

A collaborative teleconference retrospectively discussing 6 independently developed virtual vascular surgery rotations to make a framework for future use.

SETTING

University of California Davis initiated a joint teleconference among the various integrated vascular surgery programs.

PARTICIPANTS

Vascular surgery faculty and residents from 6 programs participated in the teleconferences and drafting of a framework for building a virtual vascular surgery rotation.

RESULTS

Four specific domains were identified in discussing the framework to build a virtual vascular surgery rotation: planning, development, curriculum, and feedback. Each domain has specific aspects in making a virtual rotation that has applicability to other surgical rotations that seek to do the same.

CONCLUSION

Virtual vascular surgery rotations are feasible and important; these electives can be established and implemented successfully with appropriate planning and consideration. This work hopes to help programs navigate this new space in education by making it more transparent and highlighting potential pitfalls.

A Review of Robotic Interventional Neuroradiology

Robotic interventional neuroradiology is an emerging field with the potential to enhance patient safety, reduce occupational hazards, and expand systems of care. Endovascular robots allow the operator to precisely control guidewires and catheters from a lead-shielded cockpit located several feet (or potentially hundreds of miles) from the patient. This has opened up the possibility of expanding telestroke networks to patients without access to life-saving procedures such as stroke thrombectomy and cerebral aneurysm occlusion by highly-experienced physicians. The prototype machines, first developed in the early 2000s, have evolved into machines capable of a broad range of techniques, while incorporating newly automated maneuvers and safety algorithms. In recent years, preliminary clinical research has been published demonstrating the safety and feasibility of the technology in cerebral angiography and intracranial intervention. The next step is to conduct larger, multisite, prospective studies to assess generalizability and, ultimately, improve patient outcomes in neurovascular disease.

Enhancing Education to Avoid Complications in Endovascular Treatment of Unruptured Intracranial Aneurysms: A Neurointerventionalist's Perspective

It is of utmost importance to avoid errors and subsequent complications when performing neurointerventional procedures, particularly when treating low-risk conditions such as unruptured intracranial aneurysms. We used endovascular treatment of unruptured intracranial aneurysms as an example and took a survey-based approach in which we reached out to 233 neurointerventionalists. They were asked what they think are the most important points staff should teach their trainees to avoid errors and subsequent complications in endovascular treatment of unruptured intracranial aneurysms. One hundred twenty-one respondents (51.9%) provided answers in the form of free text responses, which were thematically clustered in an affinity diagram and summarized in this Practice Perspectives. The article is primarily intended for neurointerventional radiology fellows and junior staff and will hopefully provide them the opportunity to learn from the mistakes of their more experienced colleagues.

Use of Endovascular Simulator in Training of Neurosurgery Residents - A Review and Single Institution Experience

Simulators for surgical procedures and interventions have undergone significant technological advancement in the past decade and are becoming more commonplace in medical training. Neurosurgery residents across multiple training levels underwent performance evaluation using a neuro-interventional simulator, employing a variety of metrics for assessment. We identified seven core metrics used in the evaluation of neurosurgery residents performing simulated mechanical thrombectomies. Additionally, a systematic PubMed search for studies related to Neurointerventional Radiology training via simulation was performed. The purpose of this study is to examine the validity and benefits of training with these simulation devices and compare our institution's experience. Additionally, an exploration of their applicability to neurosurgery resident training is discussed.

Impact and prevention of errors in endovascular treatment of unruptured intracranial aneurysms

BACKGROUND

Preventing errors and complications in neurointervention is crucial, particularly in the treatment of unruptured intracranial aneurysms (UIAs), where the natural history is generally benign, and the margin of treatment benefit small. We aimed to investigate how neurointerventionalists perceive the importance and frequency of errors and the resulting complications in endovascular UIA treatment, and which steps could be taken to prevent them.

METHODS

An international multidisciplinary survey was conducted among neurointerventionalists. Participants provided their demographic characteristics and neurointerventional treatment volume. They were asked about their perceptions on the importance and frequency of different errors in endovascular UIA treatment, and which solutions they thought to be most effective in preventing these errors.

RESULTS

Two-hundred-thirty-three neurointerventionalists from 38 countries participated in the survey. Participants identified errors in technical execution as the most common source of complications in endovascular UIA treatment (40.4% thought these errors constituted a relatively or very large proportion of all complication sources), closely followed by errors in decision-making/indication (32.2%) and errors related to management of unexpected events (28.4%). Simulation training was thought to be most effective in reducing technical errors, while cognitive errors were believed to be best minimized by abandoning challenging procedures, more honest discussion of complications and better standardization of procedure steps.

CONCLUSION

Neurointerventionalists perceived both technical and cognitive errors to be important sources of complications in endovascular UIA treatment. Simulation training, a cultural change, higher acceptance of bail-out strategies and better standardization of procedures were perceived to be most effective in preventing these.

Current and future usefulness and potential of virtual simulation in improving outcomes and reducing complications in endovascular treatment of unruptured intracranial aneurysms

BACKGROUND

Simulation training has been used in the aviation industry and surgical specialties for many years, but integration into neurointerventional practice is lagging behind.

OBJECTIVE

To investigate how neurointerventionalists perceive the usefulness and limitations of simulation tools for the treatment of unruptured intracranial aneurysms (UIAs), and to identify simulation applications that were perceived to be most valuable for endovascular UIA treatment.

METHODS

A web-based international multidisciplinary survey was conducted among neurointerventionalists. Participants were asked for their perceptions on the usefulness of current simulation tools and the potential impact of future simulation tools in endovascular UIA treatment. They identified simulation applications that could add most value to endovascular UIA treatment and help to specifically reduce endovascular UIA treatment complications.

RESULTS

233 neurointerventionalists from 38 countries completed the survey, most of whom (157/233 (67.4%)) had access to a simulator as a trainee, but only 15.3% used it frequently. Most participants (117/233 (50.2%)) considered currently available simulation tools relatively useful for endovascular UIA treatment, with greater value for trainees than for staff. Simulation of new devices (147/233 (63.1%)) and virtual practice runs in individual patient anatomy (119/233 (51.1%)) were considered most valuable for reducing endovascular UIA treatment complications.

CONCLUSION

Although neurointerventionalists perceived currently available simulation tools relatively useful, they did not use them regularly during their training. A priori testing of new devices and practice runs in individual patient anatomy in a virtual environment were thought to have the greatest potential for reducing endovascular UIA treatment complications.